Direct Ophthalmoscopy “THE EYE IS A WINDOW TO SYSTEMIC DISEASE” Sandra Tubito, O.D. July 2007

Discussion Outline Why ophthalmoscopy? Types of ophthomoscopy Direct ophthalmoscope Examination Procedure Setting External Exam Internal Exam What you should see Pathology Questions

Why ophthalmoscopy? Only way (and place in the body) that veins and arteries can be seen in their natural state, non-invasively. Part of general optical screening where direct observation of the structures of the fundus may show: Disease of the eye itself (e.g. glaucoma, retinal detachment) Abnormalities indicative of disease elsewhere in the body (e.g. diabetes, hypertension) Evaluation of ocular complaints

Types of Ophthalmoscopes Direct ophthalmoscope Indirect ophthalmoscope

Types of Ophthalmoscopes Direct X15 magnification 10° field of view Real image Monocular Undilated pupil Maximum resolution of 70µm Indirect X2-3 magnification 30° field of view Inverted and upside down image Binocular Dilated pupil Maximum resolution of 200µm

Direct Ophthalmoscope Illuminating system Light bulb Lenses Reflector Aperture stops and filters Different sized stops to change illumination of the retina Green (red free) filter Viewing system Sight hole (3mm in diameter) Focusing lenses

Direct Ophthalmoscope

Examination Procedure Setting Dark room Seat patient in comfortable chair with head rest Ask patient to look at a slightly elevated target on opposite wall

Examination Procedure External Exam Look at R eye with R eye (L with L) Place hand on shoulder or forehead Change viewing angle to 15° to avoid light reflex of cornea

Examination Procedure External Exam Red Reflex - hold ophthalmoscope at ~50cm and look through sight hole at the ocular media. Find the red reflex in the pupil. Opacities (eg cataracts) can be seen. Place +8.00D lens in sight hole and move to ~10cm to inspect anterior structures: lids/lashes conjunctiva cornea

Examination Procedure Internal Exam Turn focus wheel to bring anterior chamber and iris into focus Gradually reduce power in ophthalmoscope to focus on internal structures: Lens Vitreous Retina

Examination Procedure Internal Exam Continue turning focus wheel to bring retina/vessels in focus Follow the vessels to the disc The ‘arrow’ point to the disc Examine the disc, vessels, retina, & macula.

Things you should see The optic nerve head Appearance – shape/size (1.5mm in diameter) Color – disc is pale pink, cup is whitish Elevation – should be flat Rim – clear and distinct Cup/Disc ratio Ratio of the diameter of the cup to the diameter of the disc

Cup /Disc ratio

Things you should see Retinal vessels Follow vessels from disc Arteries Lighter in color, smaller Veins Darker in color, larger May spontaneously pulsate at the disc (80%) The ratio of the artery :vein diameter is normally ~ 2:3 Follow vessels from disc Look at arterio-venous crossings for abnormalities (nicking, compression, elevation, deviation) Check arterial light reflex. This will get whiter and thicker in arteriosclerosis

Arteriovenous changes Tapering concealment of the vein appearing as ‘nicking’ Elevation of the vein over the artery Deviation of the vein out of its path Compression of the vein at the arterio-venous crossing, causing stenosis of the distal vein

Things you should see Retina Check the background retina Look for color differences areas of hyper or hypo pigmentation Scarring Raised areas Hemorrhages, microaneurisms Cotton wool exudates Hard exudates A more peripheral view can be obtained by having the patient look in different directions OD OS

Things you should see Fovea and Macula Change sight hole to the smallest aperature Have patient look at the light Temporal and slightly inferior to the disc Slightly darker than rest of retina Central depression/reflex - fovea

Pathology - The optic nerve Optic atrophy

Pathology - The optic nerve “Choked disc” or Papilledema

Pathology – The optic nerve Glaucomatous cupping

Pathology - The optic nerve Papilledema with papillary hemorrhages Disc neovascularization

Pathology – Retina / Vessels Arterial occlusions

Pathology – Retina / Vessels Circinate exudates

Pathology – Retina / Vessels Intra-retinal hemorrhages

Pathology – Retina / Vessels Cotton wool spots

Pathology – Retina / Vessels Neovascularization

Pathology - Retina / Vessels Arterial plaques

Pathology – Retina / Vessels Venous occlusions

Pathology - Macula Drusen

Age related macula degeneration Pathology - Macula Age related macula degeneration Hemorrhagic phase

Exudative age related macular degeration Pathology - Macula Exudative age related macular degeration

QUESTIONS?